Quality and Safety
Correct Patient/Procedures/Site in NSW

Literature review

more: Not until the late 1990s, after the publication of the National Academy of Medicine's treatise "To Err Is Human," did safety standards specifically for patients begin to be considered in operating room practices. This report and other studies documented operating room mistakes including, for example, operations on the wrong hand or limb, operations on the wrong patient, and the performance of wrong procedures. Cases have also been documented of sponges or instruments being left by mistake inside patients following surgery. Poor communication is the most common root cause of errors. This article explores these issues and explains procedures and protocols developed to reduce surgical errors.
more: In 2000, a report was published that focused on the high rate of medical errors in the United States. Wrong site surgery is defined as any surgery performed on the wrong site or patient or performing the wrong procedure. Since January 1995, 197 wrong site surgeries have been reported through the Joint Commission on Accreditation of Healthcare Organizations sentinel event reporting system. Incidents of wrong site surgery should not happen. The perioperative health care team composed of nurses, physicians, anesthesia care providers, unlicensed assistive personnel, admission workers, clerks, and other ancillary staff members must make patient safety an uncompromising goal. This article describes the problem and identifies potential causes for incidences of wrong site surgery. The article also describes steps to act on AORNs patient safety initiative, which includes five suggestions for the development of any surgical site verification policy. Using these suggestions as guidelines for developing a policy and procedure will help decrease the risk of avoidable errors. Publication Types: Review
more: Surgical procedures undertaken at the wrong site represent a potentially devastating event for everyone involved. Wrong site surgery is defined as surgery performed at the incorrect anatomical site--either the wrong side (left leg instead of right) or the incorrect anatomical location or level (incorrect finger on the correct hand). The National Patient Safety Agency (NPSA) and the Royal College of Surgeons of England (RCS) last year issued a joint alert (NPSA 2005a) to promote correct site surgery. This aims to clarify the steps required and ensure that the intended and correct surgical procedure is performed on the correct patient at the correct site.
more: Ensuring patient safety in the operating room begins before the patient enters the operative suite and includes attention to all applicable types of preventable medical errors (including, for example, medication errors), but surgical errors are unique to this environment. Steps to prevent wrong-site, wrong-person, or wrong-procedure errors have been recommended. Prevention of surgical errors requires the attention of all personnel involved in the patient's care.
more: When procedures and processes to assure patient location based on human performance do not work as expected, patients are brought incrementally closer to a possible "wrong patient-wrong procedure'' error. We developed a system for automated patient location monitoring and management. Real-time data from an active infrared/radio frequency identification tracking system provides patient location data that are robust and can be compared with an "expected process'' model to automatically flag wrong-location events as soon as they occur. The system also generates messages that are automatically sent to process managers via the hospital paging system, thus creating an active alerting function to annunciate errors. We deployed the system to detect and annunciate "patient-in-wrong-OR'' events. The system detected all "wrong-operating room (OR)'' events, and all "wrong-OR'' locations were correctly assigned within 0.50+/-0.28 minutes (mean+/-SD). This corresponded to the measured latency of the tracking system. All wrong-OR events were correctly annunciated via the paging function. This experiment demonstrates that current technology can automatically collect sufficient data to remotely monitor patient flow through a hospital, provide decision support based on predefined rules, and automatically notify stakeholders of errors. PMID: 16224648 [PubMed - indexed for MEDLINE]
more: BACKGROUND: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. METHODS: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions. RESULTS: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included "occasion" (45.7% of instances) where timing was poor; "content" (35.7%) where information was missing or inaccurate, "purpose" (24.0%) where issues were not resolved, and "audience" (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. CONCLUSION: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR. PMID: 15465935 [PubMed - indexed for MEDLINE]
more: BACKGROUND: As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), wrong site surgery includes wrong side or siteof the body, wrong procedure, and wrong-patient surgeries. Although many health care organizations are implementing guidelines and procedures to decrease the occurrence of wrong site surgery, numerous barriers to their effectiveness have been identified. HUMAN FACTORS ENGINEERING (HFE) ANALYSIS: A human factors system analysis can be used to better understand how elements of a work system combine andinteract to contribute to breakdowns in the system. A case study of wrong site surgery in an outpatient setting illustrates how the different work systtem elements can contribute to the occurrence of a wrong site surgery. In analyzing the care process, it is particularly important to identify the transitions of care, which can be sources of patient safety problems when deficits in communication and information transfer occur (for example, miscommunication, information not transmitted on time, wrong information transmitted, misunderstanding of the information transmitted). RECOMMENDATIONS: After a wrong site surgery, conduct a root cause analysis that uses the work system model and includes a surgery care process analysis similar to the one described in the case study; collaborate with human factors engineers to learn how to apply the work system model; apply the work system model to process analysis; and optimize work systems.
more: BACKGROUND: Wrong-site orthopaedic surgery is an uncommon, devastating, and preventable complication. The sole responsibility for avoiding this inadvertent event has historically been placed on physicians, nurses, and ancillary health-care personnel. Very little attention has been focused on the role of the patient. The successful outcome of any surgical or medical intervention requires an interactive doctor-patient relationship. The hypothesis of this study was that a substantial number of patients who undergo elective orthopaedic surgery do not comply with instructions designed specifically to prevent wrong-site surgery. METHODS: We prospectively evaluated the frequency with which 100 consecutive patients in a private foot-and-ankle practice followed the explicit preoperative instruction, before they underwent elective orthopaedic surgery, to mark "NO" on the extremity that was not to be operated on. Full compliance was defined as a mark on the correct extremity consistent with the instructions. Partial compliance was defined as a mark that was different from that requested by the specific preoperative instructions, and noncompliance was defined as the absence of any mark. Specific demographic and surgical factors were recorded from medical charts and compared between compliant and noncompliant patients. RESULTS: Fifty-nine of the 100 patients marked the extremity correctly, thirty-seven made no mark, and four were considered partially compliant. Of the ten patients with a Workers' Compensation claim, seven were noncompliant compared with thirty (33%) of the ninety patients who had not made a Workers' Compensation claim (p = 0.023). Patients who had had a previous related surgical procedure also had a significantly higher rate of noncompliance (51%; nineteen of thirty-seven) compared with those with no previous surgery (29%; eighteen of sixty-three; p = 0.023). CONCLUSIONS: A surprisingly high number of patients do not comply with explicit preoperative instructions created specifically to prevent wrong-site surgery. This behavior suggests that patients expect the system to "take care of everything," despite solicitation of their active participation to avoid such adverse events. Although physicians and related health-care personnel certainly have the greatest responsibility to provide the highest possible quality of care, patients undergoing surgery must be encouraged to take a more active role in their health care in order to optimize outcome and minimize risk. Publication Types: Clinical Trial.
more: AORN is committed to promoting the identification of the correct surgical site. Using the suggested risk-prevention strategies when developing policies and procedures will reduce the risk of error. AORN's position statement on correct site surgery is available on AORN Online (i.e., http://www.aorn.org/about/positions/correct site.htm). Other resources can be found on the Patient Safety First web site (i.e., http://www.patient safetyfirst.org). As patient advocates, perioperative RNs should communicate with all members of the surgical team to verify the correct surgical site. Individual facility policy should clearly delineate the role and responsibility of the physician and other team members in marking and verifying the patient's-identity and the correct surgical site, procedure, and laterality. Perioperative nurses also should think about the last time an error or a near miss related to wrong site surgery occurred. Compare your facility's current policy and procedure to JCAHO recommendations and work within your facility to develop, implement, and monitor a collaboratively developed, multidisciplinary policy and procedure. If your facility has not addressed the issue of wrong site surgery, learn more about why this problem occurs and see what you can do to make correct site surgery an expectation--100% of the time. PMID: 12463090 [PubMed - indexed for MEDLINE]
more: BACKGROUND: Lehigh Valley Hospital's (LVH's; Allentown, Penn) interdisciplinary quality improvement program Primum Non Nocere (PNN), or First Do No Harm, is composed of 12 quality improvement (QI) projects that are a combination of ongoing operations improvement projects and new projects in patient safety. The projects stress delivery of cost-effective medical care while reducing preventable adverse events through improved communication, process redesign, and evidence-based protocol use. EXAMPLE: WRONG-SITE SURGERY: In response to an initial alert warning in 1998, LVH developed a policy of marking "yes" on the surgical site and "no" on the other side. However, several near misses occurred, and a root cause analysis indicated that the policy was not always followed for some very specific reasons. For example, the operative record included no prompt to address laterality, and the procedures in which laterality should be addressed were never specified. Interventions to address these issues were quickly developed that were in keeping with the recommendations outlined in a second alert warning on the issue in December 2001. A year after these stepwise changes, compliance with the policy is almost 100%, and there have been no further near misses. DISCUSSION: Specific project barriers included the initial challenge of changing the mindset in the institution from gradual change on a grand scale to smaller, more rapid changes, analyses, and actions. Another issue identified early in the initiative was the tendency of project groups to outline elaborate process improvements without determining how to measure and monitor success. A project sustainability is inherently linked to its initial strengths and the successful solutions to barriers that are encountered. PMID: 12101549 [PubMed - indexed for MEDLINE]
more: Abstract BACKGROUND: Over the past decade, wrong-site surgery has been a popular topic of discussion, not only in medical and legal journals but also in the mainstream press. Marking of the surgical site according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Universal Protocol was implemented at our institution to help reduce the number of wrong-site operations. In this study, we determined whether marking of the site affected the sterility of the surgical field. METHODS: The study included twenty volunteers. The right forearm was used as the experimental (marked) arm and the left forearm, as the control arm. The experimental forearms were marked with a surgical marker as described by the protocol. Both upper extremities were then sterilized from the antecubital fossa to the phalanges with a 7.5% povidone-iodine scrub followed by the application of a 10% povidone-iodine paint. Swabs were used to obtain samples from the experimental and control arms as well as from the marker and were sent for microbiological culture and analysis. RESULTS: No growth was seen in the cultures of the swabs used on the experimental or control arms or on the marking pens. CONCLUSIONS: Preoperative marking of surgical sites in accordance with the JCAHO Universal Protocol did not affect the sterility of the surgical field, a finding that provides support for the safety of surgical site marking.
more: Abstract All surgical procedures have a risk of complications, many of which cannot be avoided completely regardless of the experience and expertise of the surgeon, the surgical team, or the hospital staff. Wrong-site surgery is a relatively uncommon complication that is easily preventable. The "Sign Your Site" protocol is a simple, straightforward program that requires only a minimal amount of time to eliminate the risk of wrong-site surgery, and it should be standard policy in healthcare institutions. [References: 14]
more: Abstract OBJECTIVE: The purpose of this study was to develop a system to prevent laterality errors while performing peripheral nerve blockade. CASE REPORT: The report depicts 2 cases of peripheral nerve blocks being performed on the wrong (nonoperative) extremity. An analysis of the circumstances in each case reveals distractions, schedule changes, and communication breakdown, which contributed to the error. A protocol to prevent these errors from occurring in the future, based on the Joint Commission on Accreditation of Healthcare Organizations guidelines, to eliminate "wrong-site" surgical procedures is developed and discussed. CONCLUSIONS: The anesthesiologist plays an important role in preventing wrong-site peripheral nerve blockade and surgery. The protocol developed for "Pre-Anesthetic Site Verification" as a supplement to our preoperative site verification policy is invaluable in preventing wrong-site anesthesia and surgery.
more: Recent issues of this journal may be available full text online Abstract OBJECTIVES/HYPOTHESIS: Mirror-image reversal of coronal computed tomography (CT) scans can be a significant problem in patient care, potentially leading to wrong-sided surgery and malpractice suits. There is no literature describing the problem of mirror-image reversal of coronal CT scans. Generally, medical errors are not widely published: however, with the emphasis on reduction of errors in medicine, this topic should be openly discussed. STUDY DESIGN: Retrospective review of patient care and an assessment of current methods. METHODS: Two cases of mirror-image reversal of coronal CT scans were reviewed, and the authors found that each case represented a different type of error. In the first case, the error was recognized in the operating room. The second case resulted in wrong-sided surgery, and a lawsuit was filed. These two separate occurrences led to a review of the methods for determining right versus left side for orienting and labeling of CT scans. Orientation of coronal scans depends on whether the patient is prone or supine. Thus, technician input is required. If a labeling mistake is made, radiologists may not readily catch the mistake because of the symmetry of the head and neck anatomy. RESULTS: A review of the markings on each scan should provide the otolaryngologist with enough information to determine whether the scan is mislabeled. CONCLUSION: The incidence of mislabeled coronal CT scans is unknown. This error can result in inappropriate patient care and lawsuits for wrong-sided surgery. Awareness of the potential problem and open discussion of interpretation and prevention are necessary.
more: Abstract OBJECTIVES: The aim of the study was to investigate the effectiveness of an educational program on the reduction of the incidence of wrong-site tooth extraction at the outpatient department of a university hospital in Taiwan. STUDY DESIGN: Data collected from cases of wrong-site tooth extraction during 1996 to 1998 were used to develop a specific educational intervention that was implemented from 1999 to 2001. The annual incidence of erroneous extraction was compared between the preintervention and intervention periods. The factors contributing to wrong tooth extraction were also analyzed. RESULTS: The annual incidence rates of erroneous extraction from 1996 to 1998 were 0.026%, 0.025%, and 0.046%, respectively. During the intervention period from 1999 to 2001, wrong-site tooth extraction did not occur at the department. There was a significant difference in the incidence of erroneous extraction between the preintervention and intervention periods (P<.01). Cognitive failure was the most frequent form of active failure responsible for wrong-site tooth extraction, whereas communication and training were found to be major latent factors contributing to these errors. CONCLUSIONS: Our results suggest the effectiveness of an educational program comprising case-based materials, information feedback, and clinical guidelines in reducing the incidence of wrong-site tooth extraction.